Military Medicine最新文献

Introduction: Role 2 (R2) U.S. military treatment facilities provide lifesaving far forward damage control resuscitation and surgery. Given the austere conditions at R2s, infection risk is a major concern. We aimed to evaluate the infection rate after external fixation (EF) in military casualties based on where in the evacuation pathway the EF was performed, hypothesizing that lower-echelon EF would be associated with increased infections.

Materials and methods: The Department of Defense Trauma Registry (DoDTR) was retrospectively reviewed from 2003 to 2024. Non-U.S. military patients, deaths, and burns were excluded. Lower-echelon EF was defined as the first EF performed at R2, or Role 3 (R3) in cases of R2 bypass. Infection was defined as any one of seventeen infectious complications recorded in the DoDTR. We evaluated the independent association of lower-echelon EF on both wound infection (WI) and overall infection using multiple regression.

Results: In 6,115 patients, 2,529 met inclusion criteria, of whom 646 (25.5%) developed postoperative infection. 19.0% of all EFs were placed at R2, 67.7% at R3, 5.4% at Role 4 (R4), and 7.8% at R4-Continental United States (R4c). Overall infection rate after EF was 19.2% for R2, 24.9% for R3, 19.8% for R4, and 38.8% for R4c (25.5% overall). Wound infection was the most common infectious complication at (8.6% after EF at R2, 14.5% for R3, 15.3% for R4, and 24.5% for R4C, 15.2% overall). On adjusted analysis, higher-echelon EF was independently associated with WI and overall infection: adjusted odds ratio of 1.718 (97.5% CI, 1.311-2.250), and 1.514 (97.5% CI, 1.208-1.899), respectively.

Conclusions: For U.S. military casualties, lower-echelon external fixation is associated with decreased infection despite the austere setting. Although this study is unable to elucidate the specific factor(s) responsible for this association, it highlights the need to maintain orthopedic expertise close to point-of-injury and for future work to identify the specific characteristics of either the patients who receive lower-echelon EF, their injuries, or the EFs at the Role 2 and Role 3 facilities themselves that are responsible for this association.

Background: Whole blood is commonly used for casualty resuscitation in the prehospital setting. According to the 2021 Committee on Tactical Combat Casualty Care guidelines, whole blood is the preferred fluid for resuscitating casualties with signs of hemorrhagic shock, followed by fresh whole blood (FWB). There is limited literature on soldiers' physical and cognitive performance following donation, particularly regarding their small marksmanship accuracy immediately after 1 unit of FWB donation. Current research on marksmanship accuracy post-FWB donation among military personnel is limited to the Norwegian and Israeli militaries. The lack of Department of Defense clinical practice guidelines restricting soldiers' duties after FWB donation highlights the paucity of data. This study evaluates the effects of FWB donation on U.S. Army conventional soldiers' small marksmanship accuracy and provides quantifiable data for future U.S. Army post-FWB donation guidelines.

Methods: This was a prospective, controlled trial assessing small arms marksmanship accuracy pre- and post-FWB donation with a convenience sample of conventional U.S. Army conventional soldiers, using an indoor Electronic Skill Trainer (EST) simulator. The primary outcome assessed for a difference in small arms marksmanship accuracy following FWB donation. Participants served as their own controls, with baseline marksmanship accuracy testing performed before FWB donation and again immediately after. Secondary outcomes were the participants' pre- and post-FWB donation self-efficacy scores.

Results: Sixteen participants completed small arms marksmanship accuracy testing pre- and post-FWB donation. We found no significant difference in small arms marksmanship accuracy following FWB donation (24.69 vs. 26.32, P = .38). Similarly, we evaluated small arms marksmanship accuracy self-efficacy via a Bandura Scale and found no significant difference between pre-and post-FWB donation (86.25 vs. 85.63, P = .67).

Conclusions: The accuracy of U.S. Army conventional soldiers small arms marksmanship was not significantly different after donating 1 unit of FWB. This study provides data on post-FWB donation marksmanship accuracy, which could inform future guidelines for soldiers returning to duty after donating 1 unit of FWB blood. Larger, comparative studies need to be performed to further investigate soldiers' post-FWB donation marksmanship accuracy.

Introduction: Stress from the COVID-19 pandemic may have had a profound impact on the mental health of Reserve and National Guard (RNG) women Veterans, especially if they have a history of traumatic brain injury (TBI). This cross-sectional study aimed to assess the potential mediating effect of stress stemming from the COVID-19 pandemic on the association between TBI and depression symptoms.

Materials and methods: Women RNG Veterans between the ages of 18 and 60 were interviewed about their lifetime history of TBI, symptoms of depression, and any stressful experiences resulting from the COVID-19 pandemic. Using interview responses, we utilized exploratory factor analysis (EFA) to approximate COVID-19 stress. We then used the results from EFA in mediation analysis of linear regression models of TBI history on depression. Ethical approval for the study and analyses was obtained from the University of Iowa Institutional Review Board (IRB) (IRB ID #201911171).

Results: We identified 9 items across a 3-factor model ("Stress about Daily Necessities," "Stress about Health," "Increasing Alcohol Use") that approximated COVID-19 stress. Of the 351 women Veterans included in this study, 145 (41.3%) had history of TBI. Those with TBI had more severe symptoms of depression (risk difference: 1.81, 95% CI: 0.41-3.20) than those without TBI. Total COVID-19 stress mediated the association between TBI and symptoms of depression (indirect effect: 0.67; 95% CI: 0.24-1.21; 35.5% mediated). Stress about Daily Necessities alone also mediated the TBI-depression association (indirect effect: 0.65; 95% CI: 0.44-0.84; 34.8% mediated).

Conclusions: Women RNG Veterans with prior TBI reported more severe depression symptoms than those without TBI, and these depression symptoms seem to be exacerbated upon the introduction of stress because of the COVID-19 pandemic. Future research of this complex TBI-stress-depression relationship should be longitudinal in nature, especially as the long-term effects of the COVID-19 pandemic continue to emerge, to understand how events that introduce significant economic and health-related consequences affect how symptoms of depression and responses to stress evolve over time.

Introduction: Loneliness among older adults is a significant public health concern. There is a critical need to develop effective, tailored strategies to combat loneliness that accounts for the diverse nature of older adult populations, including those with unique life experiences, such as Veterans. In order to develop and implement these strategies and meet the specific needs of the diverse older population, the research field requires a comprehensive understanding of the various factors that contribute to loneliness across different subgroups of older adults, including Veterans and civilians. In this study, we aimed to address this research gap by investigating and comparing characteristics associated with loneliness among both older Veterans and civilians.

Materials and methods: In this cross-sectional exploratory study, we used data from the RAND Health and Retirement Study Longitudinal File 2020, derived from the Health and Retirement Study and provided by the RAND Center for the Study of Aging (N = 5,259) to assess and compare characteristics associated with loneliness among older Veterans and civilians. We conducted logistic regression and moderation analyses to investigate associations between demographic, health, health behavior, and psychosocial factors and loneliness.

Results: Our results showed significant positively associations between loneliness and being unmarried/unpartnered, greater depressive symptoms, and greater negative affect for both Veterans and civilians. Similarly, we found significant negative associations between loneliness and greater life satisfaction and positive affect for both subsamples. Our results showed that having health conditions that limit an individual's ability to work was a unique risk factor for loneliness among Veterans. Moderation analyses revealed that the positive association between being unmarried/unpartnered and loneliness and the negative association between rural residence and loneliness were significantly greater for Veterans, as compared to civilians.

Conclusions: Our findings suggest the importance of considering life course perspectives and developing targeted interventions to address loneliness among older adults, particularly Veterans. Future research should focus on longitudinal studies to investigate the effectiveness of such interventions, explore protective factors, and examine the impact of social interventions on reducing loneliness in these populations.

Historically, military anatomic pathology (AP) services have been significantly compartmentalized, with each branch independently executing its laboratory support mission. The result is redundant and costly duplication of nearly identical services in close geographic proximity. The duplication of AP services disperses the overall caseload, resulting in pathologist diagnostic acumen atrophy, excessive support personnel requirements, inadequate utilization of subspecialty expertise, and overall lower-quality patient care. Unlike many medical specialties, implementing AP services does not require direct patient interaction and is principally not as time-sensitive as other clinical laboratory testing. The practice of AP is conducive to a more consolidatory paradigm to achieve economies of scale. Pathology service unification would also afford the stationing of predominantly subspecialists at tertiary care centers to handle higher caseloads. Larger groups of pathologists increase patient safety enhancing peer-to-peer and subspeciality quality assurance processes during case review. Conversely, the nature of clinical pathology services requires a more widespread presence-even at the smaller, auxiliary clinics throughout the military health system. Clinical pathology services would also benefit from additional triservice cooperation including standardization of quality management processes, increased resource sharing, exchange, and cooperative contingency planning. Laboratory directorships also benefit from consolidating expertise, where pathologists could be physically located at a central site with remote oversight of laboratory services. Here, we propose a holistic triservice consolidation plan for military pathology to optimize resource utilization and ultimately realize the overarching strategic plan for military medicine set forth by the Defense Health Agency.

Introduction: Military satisfaction is an important determinant for military retention and subsequently military readiness. Military readiness is also impacted by food insecurity, which affected 25% of active duty service members in 2018 and 2020, much higher than the 10% prevalence observed in civilians. The objective of this study is to estimate the association between food insecurity and 3 indicators of satisfaction with military life: active duty service member's overall satisfaction with military life, active duty service member's intent to leave the military, and married active duty service members' perceptions regarding spousal desire to leave the military.

Materials and methods: The 2020 Status of Forces Survey of Active Duty Members is a probability-based sample of all active duty service members in the U.S. Military (n = 12,324). Weighted logistic regressions were used to estimate the associations between food insecurity and retention indicators controlling for observable confounders. This study was approved as public health practice by the Defense Centers for Public Health-Aberdeen.

Results: Respondents with either low food insecurity (adjusted odds ratio (AOR): 1.45; 95% confidence interval (CI), 1.18-1.78) or very low food insecurity (AOR: 1.68; 95% CI, 1.30-2.16) had greater odds of dissatisfaction with military way of life compared to food secure respondents. Additionally, very low food security was associated with greater odds of spousal desire to leave the active duty military. Respondents who reported they had lower levels of financial security had lower satisfaction with the military way of life, greater intent to leave the military, and greater spousal desire to leave active duty.

Conclusions: In the present era of an all-volunteer military, novel strategies are needed to recruit and retain service members and their families. Although food insecurity was only associated with overall satisfaction with the military way of life, lower financial security was associated with satisfaction and intent to leave the military. Future studies could determine how financial security, including food insecurity, can be bolstered among active duty service members to increase retention and maintain military readiness.

Introduction: This narrative review highlights the impact and epidemiology of post-COVID conditions (PCC, 'Long COVID') in military service members and beneficiaries, characterizing the threat of Long COVID to military readiness. We leveraged this review to propose a Long COVID research road map for Military Health System (MHS)-based studies, identifying key questions and knowledge gaps that the Department of Defense research enterprise is well-positioned to address.

Materials and methods: We searched MEDLINE (PubMed) in addition to MHS conference abstracts and websites, bibliographies of relevant published articles and https://clinicaltrials.gov/.

Results: Multiple studies in U.S., U.K., and European military service members have noted medically attended and patient reported post-acute sequelae and symptoms across the domains of cardiorespiratory, neurocognitive, and mental health. Studies have also noted an association with SARS-CoV-2 infection and fitness in young adult service members, but the ongoing prevalence, morbidity, and functional impact of Long COVID in military populations in the current era remains unclear. All identified studies have limitations.

Conclusions: Considerable research has been conducted to understand the risk of and risk factors associated with Long COVID in active duty, much in the earlier pandemic period. Future research priorities include establishing Long COVID definitions most relevant to active duty personnel and conducting studies to delineate, treat, and prevent Long COVID's impact on cognitive, cardiorespiratory, and overall health and fitness for duty. Many considerations in this review article may also apply to post-acute sequelae from other infectious diseases, which pose risks to military health and readiness, including future respiratory virus pandemics.

Introduction: An estimated 5.6 million individuals in the U.S. experience limb loss and absence, but national estimates exclude Military Health System (MHS) beneficiaries. The purpose of this study is to characterize MHS beneficiaries with limb loss and absence and estimate incidence and prevalence.

Material and methods: We conducted a retrospective cohort study using data from the MHS Information Platform. Descriptive statistics were used to characterize the study population, including demographics, level of limb loss and absence, and etiology. Bivariate analyses between demographic characteristics and level of limb loss were conducted using analysis of variance and chi-square tests. The sample includes MHS beneficiaries diagnosed with limb loss or absence from 2005 to 2023. The study was determined exempt human subjects research by the Uniformed Services University of the Health Sciences Institutional Review Board.

Results: The cohort (118,587) was 64.6% male and 35.4% female, with mean age 58 years (SD = 23.4). Racial distribution included 49.8% White, 6.4% Black, and approximately 42.1% other or unknown. Service branches were Army (41.0%), Air Force (26.7%), Navy (19.7%), Marine Corps (7.0%), other (3.9%), Coast Guard (1.7%), and Space Force (0%). The majority were retired (46.2%) or other (32.0%), with a smaller portion active duty (12.0%) and dependents (9.9%). Levels of limb loss were 72% lower limb, 26.1% upper limb, and 2% unspecified. Causes included acquired absence (53.8%), traumatic amputation (34%), and congenital absence (12.1%). Bivariate analysis showed significant associations between demographics and limb loss levels (P = .000). Incidence (z = -2.43, P = .015) and prevalence (z = -13.69, P = .000) rates declined over 19 and 8 years, respectively.

Conclusion: This study highlights demographic characteristics, causes, and declining rates of limb loss and absence among MHS beneficiaries, providing a foundation for future research and informing clinical practices and policies to enhance care and resource allocation.

Introduction: Generating clinical narrative summaries is a critical use case for the Military Health System. This study evaluates the performance of detailed versus vague prompts in generating summaries that yield accurate, bias-free, and meaningful outputs.

Materials and methods: Eight anonymized large language models (LLMs) were evaluated by volunteer clinicians for clinical narrative summary generation from October through November of 2024. Eight clinical scenarios were presented to each model with structured and vague prompt variations, and the responses were evaluated for conformance, task adequacy, hallucinations, and bias.

Results: Both approaches were comparable in conforming to instructions (64%). The structured approach was more likely to produce a clinically adequate summary (39% compared to 9%) but also more likely to introduce hallucinations and bias.

Discussion: The structured prompt, following best practices for prompt engineering, produced a superior response but was prone to hallucinations. This could be mitigated with additional tuning. None of the models tested reliably produced clinically usable summaries.

Conclusion: Efficient generation of clinical summaries is critical for the Military Health System. Using a structured prompt that employs role, task, tone, and format increases the output quality. Institutions seeking to use LLMs to summarize clinical notes may have more success with a structured approach but need to be cautious in ensuring the summary itself is true to its source documents.